Periampullary Carcinoma with ERCP-induced Pancreatitis

Clinical history: A 72-year-old female presented with chief complaints of acute pain in abdomen for the past few days. The patient had been diagnosed of a periampullary carcinoma for which she had undergone ERCP and stent placement to relieve the obstructive jaundice.
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Findings:  A CT scan was performed which showed ill-defined circumferential wall thickening in the periampullary region with grossly dilated CBD (measuring 2.0cm in diameter), dilated pancreatic duct (measuring 5mm) and a few periportal and paraaortic lymph nodes. There was mild intrahepatic biliary radical dilatation with the CBD stent in situ. The pancreatic head and uncinate process appeared bulky and mildly hypodense with evidence of a rim of fluid surrounding it and shaggy margins. Soft tissue stranding was seen surrounding these structures and extending into root of mesentery. The features were suggestive of acute edematous pancreatitis in the region of pancreatic head and uncinate process.

Diagnosis: Periampullary carcinoma with ERCP-induced pancreatitis

Discussion: Endoscopic retrograde cholangiopancreatography (ERCP) is being widely used not only for diagnostic but also a therapeutic tool for the management of various benign and malignant conditions affecting the hepatobilliary tract. The common complications are pancreatitis, hemorrhage, cholangitis and duodenal perforation. Pancreatitis is seen in 5 percent of the diagnostic and 10 percent of therapeutic cases. The diagnostic criteria for pancreatitis include two out of the following three:

1. Abdominal pain for more than 24 hours after the procedure
2. Elevated levels of serum pancreatic enzymes three times the normal value.
3. Imaging study supporting the diagnosis (CT or MRI)

CT is the primary modality used for the diagnosis of the condition. The salient features include focal enlargement of the gland with heterogeneous post contrast enhancement, hypoattenuation in areas of necrosis and peri-pancreatic fat stranding.  Air bubbles are noted in the necrotic pancreatic tissue if the area gets infected. Complications like pseudocyst, pseudoaneurysms, ascites and pleural effusion. The management protocol is same as that of any other cause of pancreatitis. Owing to the lack of specificity of pain and biochemical studies (serum amylase/lipase) in patients who have undergone ERCP, imaging plays a crucial role in diagnosis which can aid early management and avoid unfavorable consequences.

Amar Udare, MDRadiodiagnosis, Tata Memorial Hospital
Mumbai, India

References:

• Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities demonstrated with CT. RadioGraphics2001; 21: 1441–1453
• Badalov N, Tenner S, Baillie J:  The Prevention, Recognition and Treatment of Post-ERCP Pancreatitis. JOP. J Pancreas (Online) 2009, 10(2):88-97.
• Smith G, Lieberman G. An Atlas of Complications of ERCP [Internet]. Gillian Lieberman, MD ;March 2012 [cited 2012 Sep 19].Available from http://eradiology.bidmc.harvard.edu/LearningLab/gastro/Smith.pdf
• Cohen SA, Siegel JH, Kasmin FE. Complications of diagnostic and therapeutic ERCP. Abdom Imaging 1996; 21:385–394.
• Banks PA, Freeman ML; Practice Parameters Committee of the American College of Gastroenterology. Practice Guidelines in Acute Pancreatitis.  Am J Gastroenterol 2006; 101:2379-2400.